AMERICAN ACADEMY OF PEDIATRICS The Use of Whole Cow`s

AMERICAN
The
Use
ACADEMY
of Whole
Cow’s
Committee
The Committee
on Nutrition
continues
to monitor
and review
nutritional
issues
concerning
the use of
whole
cow’s
milk (WCM)
in the diets of infants.
The
goal of those
concerned
with
infant
nutrition
is the
provision
of an optimal
diet.
The recommendations
in this statement
replace
those
provided
in the 1983
statement,
“The
Use
of Whole
Cow’s
Milk
in Infancy.”
The
1983 statement
focused
primarily
on the
issue of iron nutriture
in infancy.
In a broader
context,
the statement
addressed
a substantial
number
of often
controversial
nutrition
issues,
defined
as “research
needs,”
surrounding
the
appropriateness
of using
whole
cow’s
milk
for infants
during
the
first
12
months.
The purpose
of this statement
is to provide
new recommendations
on the optimal
feeding
of infants.
The use of skim milk and reduced-fat
milk (eg,
2% milk)
remains
inappropriate
during
the first year
of life and will not be reviewed
in this statement.
REVIEW
OF PREVIOUS
STATEMENTS
During
the last 20 years,
the use of whole
cow’s
milk in infancy
has been
discussed
by the Committee
on Nutrition
principally,
but not exclusively,
in the
context
of meeting
infants’
iron needs.
In 1969,
an
extensive
commentary2
reviewed
iron
requirements
in infancy,
and in 1971,
a policy
statement3
recommended
that iron-fortified
formulas
be used
for the
first 1 2 months
of life. Those
recommendations
were
prompted
by a significant
prevalence
of iron
deficiency
in older
infants
associated
with
the extensive
use of whole
cow’s milk in later infancy.
“Fluid
whole
milk (available
in bottle
or carton)
or evaporated
milk,
both of which
contain
only trace amounts
of iron, are
substituted
at the time
of greatest
iron
need
and
highest
prevalence
of iron deficiency
anemia.”3
Several
clinical
studies
demonstrated
that feeding
iron-fortified
formulas
to infants
for the
first
12
months
resulted
in excellent
iron status.47
The Committee
believed
that adding
iron to the infant’s
major
source
of calories
(milk-based
formula)
was a practical
and effective
method
to alleviate
the high prevalence
of iron deficiency
anemia.
In 1976,
the
Committee
on Nutrition
issued
a
statement8
recommending
the use of either
iron-fortified
formula
or infant
cereal
during
older
infancy.
The Committee
noted
the following;
“Infant
formula
and other
heat-treated
milk
products
are preferable
The recommendations
in this statement
do not indicate
an exclusive
of treatment
or procedure
to be followed,
Variations,
taking into
individual
circumstances,
may be appropriate.
PEDIATRICS
(ISSN 0031 4005). Copyright
© 1992 by the American
emy of Pediatrics.
OF PEDIATRICS
course
account
Acad-
on
Milk
in Infancy
Nutrition
to fresh
[pasteurized]
cow’s
milk
as substitutes
for
breast
milk feeding
during
the first 6 to 1 2 months
of
life because
excessive
ingestion
of fresh
cow’s
milk
may contribute
to iron deficiency
by increasing
gastrointestinal
blood
lOS5.8
In 1983,
the Committee
on Nutrition
developed
a
new position,’
based
largely
on a study
by Fomon
et
al9 of gastrointestinal
blood
loss in infants
aged
4 to
6 months
fed WCM,
heat-treated
WCM,
or infant
formula.
All infants
received
supplemental
ferrous
sulfate
and ascorbic
acid. Enteric
blood
loss was greatest in WCM-fed
infants
younger
than
4#{189}
months
of
age.
In infants
between
4’/2
and
6 months
of age,
there
was
no difference
among
the
three
groups
(WCM,
heat-treated
WCM,
or infant
formula)
in the
number
of guaiac-positive
stools,
mean
hemoglobin
levels,
serum
iron
levels,
iron
binding
capacity,
or
transferrin
saturation.
Consequently,
the
1983
statement’
suggested
that
whole
cow’s
milk
could
replace
iron-fortified
formulas
when
infants
older
than
6 months
of age were
consuming
at least
one
third
of their
calories
from
supplemental
foods.
The
question
of whether
feeding
iron-fortified
formula
to
infants
for the first 6 months
of life would
be suffiaent
to prevent
iron
deficiency
during
the next
6
months
when
they
are started
on whole
cow’s
milk
could
not be answered
from the existing
data.
REVIEW
1983
OF RESEARCH
STATEMENT2
ON
MILK
QUESTIONS
POSED
THE “USE OF WHOLE
IN INFANCY.”
IN THE
COW’S
Since
the
1983
recommendations,
several
new
studies
have
been
published
that
address
the five
questions
posed
in this statement.
Results
of these
studies
require
further
refinement
regarding
the feeding recommendations
for later infancy.
1. “What
infant
is the rate and
gastrointestinal
variability
mucosal
of maturation
of
barrier function?”
The gastrointestinal
tract is immature
early
in life.
Consequently,
there
is an increased
transfer
of intact
dietary
protein
from
the intestinal
lumen
into
the
circulation
in the immediate
neonatal
period,
particularly
in preterm
infants
and infants
who
have
gut
injury.dlu
Although
controversial,
it is believed
that
increased
intestinal
permeability
may
contribute
to
the high
incidence
of cow’s
milk
protein
allergy,
a
condition
that
affects
0.4%
to 7.5%
of the infant
population.”
There
is no information
to suggest
that
WCM
is more
allergenic
than
infant
formulas
that
contain
intact
cow’s
milk proteins.
Infants
with cow’s
milk protein
allergy
should
not be fed either
WCM
or
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PEDIATRICS
Vol. 89 No.
6
June
1992
1105
formulas
containing
intact
WCM
proteins.
In nonallergic
infants,
the introduction
of whole
cow’s
milk
should
be based
on digestive
and nutritional
considerations,
not
on the development
of the mucosal
barrier.
2. “What is the relative
importance
of the amount
and
bioavailability
of iron in the total diet when whole
cow’s milk is substituted
for iron-enriched
formula
at 6 months
of age? Does iron-fortified
cereal meet
the infant’s
need for iron?”
Six studies’2’7
(Second
National
Survey
based
Health
Department
of
on
four independent
surveys
and Nutrition
Examination
Agriculture
Food
Consump-
tion,
Ross
Mothers
Study,
and
Gerber
Nutritional
Survey)
have
been
published
to date and reviewed.
Five of the six studies
suggest
that infants
fed whole
cow’s
milk in later infancy
have
median
iron intakes
below
the recommended
daily
allowance.
These
results
clearly
indicate
that an insufficient
quantity
of
iron-fortified
infant
cereal
is currently
incorporated
into
the diet
of most
infants
to meet
iron
needs.
However,
infant
cereal
is the single
largest
source
of
iron from
infant
solid
foods
available
in the United
States.
Parents
who
feed
their
infants
whole
cow’s
milk
must
also
judiciously
select
solid
foods
that
contain
iron.
The bioavailability
of electrolytic
iron,
the form
of
iron that
is added
to infant
foods,
remains
incompletely
defined
and controversial.
Furthermore,
quantitative
studies
of electrolytic
iron
absorption
have
been
conducted
only with adult
subjects.
Electrolytic
iron is produced
by electrolytic
deposition
of iron that
is mechanically
commuted
to powder
(grade
A-131).
Fomon’8
notes
that
cereals
marketed
in the United
States
and
Canada
containing
electrolytic
iron
are
fortified
with
45 mg of iron/100
g of dry weight,
or
approximately
7 mg of iron/100
g of cereal
as fed (ie,
after
dilution
with
milk
or formula).
Forbes
et al,’9
using
a farina-based
meal,
demonstrated
absorption
of iron of a similar
particle
size to be 75%
that
of
ferrous
sulfate.
Elwood2#{176} demonstrated
that absorption of commercially
used iron powder
in baked
bread
is about
5% that of ferrous
sulfate.
Fomon,’8’2’
using
Elwood’s
data,
calculated
that
absorbed
iron
from
infant
cereal
could
only
account
for 0.12 mg of the
0.6 to 0.7 mg of absorbed
iron that infants
require
each
day.
Both
Fomon
and
Elwood
concluded
that
without
evidence
of adequate
bioavailability,
the electrolytic
iron
used
in
infant
cereals
is not
sufficient
to
meet
the iron needs
of infants
fed whole
cow’s
milk.
The
composition
of whole
cow’s
milk
(ie, high
calcium,
high
phosphorus,
and low vitamin
C) may
decrease
the bioavailability
of iron from other
dietary
sources
such
as infant
cereals.22
Three
studies2325
compared
the iron
status
of infants
receiving
ironfortified
formulas
for the first 6 months
of life and
then
fed WCM
or iron-fortified
formulas
in accordance with
the 1983 American
Academy
of Pediatrics
recommendations
for the next 6-month
period.
In all
three
studies,
iron status
was significantly
poorer
in
infants
fed WCM.
Fortification
of other
infant
foods,
including
wetpack
cereal-fruit
products,
grape
juice,
or milk
forti-
1106
USE
OF
WHOLE
COW’S
fied with
a highly
bioavailable
form
of iron (ferrous
sulfate
with vitamin
C), but less modified
than regular
infant
formula,
appear
promising,26
but largely
unexplored
in the United
States.
Haschke
et al27 demonstrated
indices
of iron adequacy
similar
to infants
fed
only iron-fortified
formula
using
meat-containing
infant foods
fortified
with
ferrous
sulfate
and ascorbic
acid that are commercially
available
in Austria
and
the Federal
Republic
of Germany,
but
not in the
United
States.
Stekel
et al28 in Chile
studied
the
bioavailability
of ferrous
sulfate-fortified
(elemental
iron,
10 to 19 mg/L)
low-fat
and whole
milks
(less
modified
than
regular
commercial
formula)
fed to
infants,
many
of whom
were iron-deficient.
Iron absorption
from milk containing
ascorbic
acid (100 mgI
L) ranged
from 5.9% to 1 1 .3% and was not influenced
by the amount
of milk fat, the addition
of carbohydrate,
or acidification.
Results
of longitudinal
field
trials of infants
from
age 3 to 1 5 months
with a fullfat iron-fortified
acidified
milk showed
effective
elimination
of iron deficiency.29
Evidence
now
suggests
that
the current
feeding
practice
in the United
States
of using
iron-fortified
cereal
does
not meet
the requirement
for iron when
WCM
is used during
the second
6 months
of life. This
may
be due to poor
compliance
or insufficient
bioavailability
of electrolytic
iron.
However,
providing
iron-fortified
formula
and
cereal
for
the
first
12
months,
as utilized
in the Women,
Infants,
and Chilthen
Program,
has been
successful
in reducing
iron
331
3. “Can the change
to cow’s milk when the infant
is 6
months
old produce
anemia
from occult blood loss
when the milk is fed in excessive
amounts
and there
is no iron supplementation?”
This
question
has been
the subject
of additional
study
and
commentary.
Both
Woodruff32
and
Wilson33
concluded
that blood
loss did occur
in infants
fed WCM
after
6 months
of age. Following
the
gastrointestinal
blood
loss
study
by Fomon
et al,9
Ziegler
et al34 used
a more
sensitive
assay
for stool
hemoglobin
in a second
study
of blood
loss in 6month-old
infants
fed either
infant
formula
or WCM
without
iron
supplementation.
Intestinal
blood
loss
increased
in 30%
of infants
fed WCM
but did not
increase
in the formula-fed
group,
even
though
all
were
previously
fed iron-fortified
formula
or were
breast-fed
in the first 6 months
of life.34 One
infant
in the WCM
group
was
removed
from
the study
because
of iron
deficiency.
The
investigators
concluded
that
infants
fed WCM
had
a nutritionally
significant
loss of iron in the stools.
These
studies
clearly
show
that blood
loss will occur in a substantial
percentage
of infants
who receive
WCM
for the first
time
after
6 months
of age.
On the basis
of these
recent
results,34
Fomon
and
Ziegler
reversed
their
earlier
positions,9
stating
that they
no longer
recommended
WCM
in the second
6 months,
but preferred
breast
milk or iron-fortified
formula
for the first 12
months
of life.35’36 The reasons
for these
recommendations
include
the substantial
enteric
blood
loss in
infants
fed WCM,
the probable
low bioavailability
of
iron absorbed
from
infant
cereals,
and the probable
Downloaded from by guest on October 1, 2016
MILK
inhibition
of
iron
concentrations
concentration
and
WCM
due
phosphorous
to
high
and
low
acid.
relative
importance
of the high solute
cow’s milk in the total feeding
6- to 12-month-old
infant?
For example,
the high-solute
load of whole
cow’s
by other foods in the diet?”
that
have
“What is the relative
importance
of the nutrients
present
in whole
cow’s milk but present
in infant
formula
and breast milk, ie, essential
fatty acids,
tocopherol,
ascorbic
acid? How much of these
nutrients
are obtained
from the other foods
commonly
used in the 6- to 12-month
age group?”
daily
allowance’2”3
linoleic
acid
energy
intake,
3%
was
for
not
formula
below
However,
the
reduced
well
below
the
not
than
median
intake
inof
dramatically
to 1 .8% of total
the recommended
level of
infants
(3.7
intake
WCM-fed
±
2.6
of
mg/d
ainvs
10.9 ± 3.1 mg/d).
Moreover,
a-tocopherol
status,
as
assessed
by plasma
concentrations,
was significantly
greater
in the formula-fed
infants
(1 14 ± 0.42
vs
0.86 ± 0.28).
The studies
of the past
7 years
demonstrate
the
difficulty
of providing
a balanced
diet for older
infants
when
WCM
replaces
breast
milk or iron-fortified formula.
Nutrients
from
commonly
consumed
.
solid
foods
do
not
complement
DEFICIENCY
AND
studies
by Oski and co-workers38
show
that
deficiency
in infants
and children
is associated
subtle
behavioral
differences.
Additional
recent
studies3942
suggest
that
iron
deficiency
in early
childhood
may lead to long-term
changes
in behavior
that
may not be reversed
even with iron supplementation
sufficient
to correct
the anemia.
Newly
published
studies
on iron
deficiency
and
behavior
show
the
importance
of iron
deficiency
in WCM-fed
infants.
The biochemical
mechanism
linking
iron deficiency
nutrients
from
and
behavior
WCM;
rather,
they exaggerate
the deficiencies
(iron,
linoleic
acid, and vitamin
E) and excesses
(sodium,
potassium,
chloride,
and protein)
in the infant’s
diet.
may
Youdim’s
group
researchers
have
be
identified
from
in experimental
shown
mechanism
in which
studies
that
the
number
These
of dopamine
is reduced
when
the
a transient
period
of
and
are not subsesupplementation.
Aland further
amplia possible
model
of a
a transient
nutritional
event
produce
long-term
changes
in the neurologic
of the brain
of the animal
studied.
Additional
is necessary
to understand
the implications
deficiency
to possible
brain
from
animals.4345
D-2 receptors
in the rat brain
experimental
animals
undergo
iron
deficiency
during
infancy
quently
restored
with
iron
though
they require
confirmation
fication,
these
studies
provide
dysfunction
may
status
research
of iron
in humans.
SUMMARY
The pediatrician
is faced
with
a difficult
challenge
in providing
recommendations
for optimal
nutrition
in older infants.
Because
the milk (or formula)
portion
of the diet represents
35%
to 100%
of total
daily
calories
and
because
WCM
and breast
milk or infant
formula
differ
markedly
in composition,
the selection
of a milk or formula
has a great
impact
on nutrient
intake.
Infants
fed
and
potassium,
reduced
the
recommended
study37
of 97 older
infants,
was significantly
lower
in
in formula-fed
ON IRON
BEHAVIOR
acid,
1’,16
In one
tocopherol
fants
of WCM
acid, but
STUDIES
Earlier
several
studies
show
of infant
formula
Substitution
take of ascorbic
NEW
iron
with
infants
fed
a markedly
increased
intake
of sodium,
potassium,
chloride,
and
protein.’2’6
The sodium
intake
(1000 mg/d)
of WCMfed infants
substantially
exceeds
the estimated
minimum
requirements
(120 mg/d
for infants
from
birth
to 5 months
old and 200 mg/day
for infants
6 to 11
months
old). By comparison,
the median
sodium
intake for formula-fed
infants
(7 to 1 2 months
old) is
580 mg/d.’2
Consequently,
the renal
solute
load
of
WCM-fed
infants
exceeds
that of formula-fed
infants
by twoto threefold
(from
approximately
1 25 to 300
mOsm).’6
Ziegler36
calculated
the potential
renal
solute load
of two
hypothetical
infants,
6- and
10months-old,
fed infant
solids
and
formula
versus
infant
solids
and WCM.
When
WCM
replaced
formula,
the potential
renal
solute
load
increased
twofold in the 6-month-old
infant
(42 vs 21 mOsm/100
kcal) and nearly
twofold
in the 10-month-old
infant
(39 vs 26 mOsm/100
kcal).
He concluded
that both
infants
exceeded
their
recommended
maximum
(33
mOsm/100
kcal) potential
renal
solute
load when
fed
WCM
and
that
WCM
feeding
would
narrow
the
margin
of safety
in situations
that may lead to dehydration.
Thus,
the high renal solute
load of WCM
was
not diluted
by other
foods
in the diet.
5.
from
instead
in
calcium
of ascorbic
4. “What is the
load of whole
regimen
of a
how much of
milk is diluted
Data
WCM
availability
of
WCM
vitamin
and
have
E, and
low
intakes
excessive
protein,
illustrating
of iron,
intakes
the
linoleic
of sodium,
poor
nutri-
tional
compatibility
of solid
foods
and WCM.
These
nutrient
intakes
are not optimal
and
may
result
in
altered
nutritional
status,
with
the most
dramatic
effect
on iron status.
Infants
fed iron-fortified
formula
or breast
milk for the first 1 2 months
of life generally
maintain
normal
iron
status.
No studies
have
concluded
that the introduction
of WCM
into the diet at
6 months
of age produces
adequate
iron status
in later
infancy;
however,
recent
studies
have
demonstrated
that iron status
is significantly
impaired
when
WCM
is introduced
into
the
diet
of 6-month-old
infants.
Data
from
studies
abroad
of highly
iron-deficient
infant
populations
suggest
that infants
fed partially
modified
milk formulas
with
supplemental
iron in a
highly
bioavailable
form
(ferrous
sulfate)
may
main-
tam adequate
iron status.
However,
these
studies
do
not address
the overall
nutritional
adequacy
of the
infant’s
diet. Such
formulas
have
not been studied
in
the United
States.
Optimal
nutrition
of the infant
involves
selecting
the appropriate
milk source
and eventually
introducing infant
solid foods.
To achieve
this goal, the American Academy
of Pediatrics
recommends
that infants
be fed breast
milk for the first 6 to 1 2 months.
The
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1, 2016 ACADEMY
AMERICAN
OF PEDIATRICS
1107
microvillus.
acceptable
alternative
to breast
milk
is ironfortified
infant
formula.
Appropriate
solid
foods
should
be added
between
the ages of 4 and 6 months.
Consumption
of breast
milk or iron-fortified
formula,
along
with
age-appropriate
solid
foods
and
juices,
during
the first
1 2 months
of life allows
for more
balanced
nutrition.
The American
Academy
of Pediatrics
recommends
that
whole
cow’s
milk
and lowiron formulas
not be used during
the first year of life.
only
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GA,
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Forbes
AL, Adams
Elwood
PC.
human
subjects
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and
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WL,
prevention
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iron
iron
Jackson
SW, Wright
RL,
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RP. The
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of ferric
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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it
has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the
American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007.
Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005.
Online ISSN: 1098-4275.
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The Use of Whole Cow's Milk in Infancy
Pediatrics 1992;89;1105
The online version of this article, along with updated information and services, is located on
the World Wide Web at:
/content/89/6/1105
PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication,
it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked
by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village,
Illinois, 60007. Copyright © 1992 by the American Academy of Pediatrics. All rights reserved. Print
ISSN: 0031-4005. Online ISSN: 1098-4275.
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